Renewal Va Item Checklist (Page 2 of 2) in pdf

Annual Certification Request

For VA Education Benefits

VA Benefits Recipient:

This Certification Request is required so our office can certify your enrollment, which is required by the Department of Veterans Affairs.

Please complete this form and return to our office as soon as possible

Academic Year (Fall to Summer) 20_________-20_________. Please submit one request per academic year.

2. Full Name (please print) ______________________________________________ Program of Study*: ___________________________

(*The DPT-Transitional Program is not eligible for certification/ VA benefits.Online Instructional Fee for BS EHS is not eligible for Certification)

3. UTHSCSA ID? ____________________

3. Are you Active Duty?

Yes

4. Do you receive Tuition Assistance, NECP, AECP, ROTC Scholarships or other Federal Funding?

Yes**

(**if Yes– you may not be entitled to full VA Education Benefits)

5. Which VA Education Chapter will you be using?

CH 30

CH 33**

CH35

CH 1606

CH 1607

(**if applying for CH 33-Post 9/11 you MUST provide copy of updated Certificate of Eligibility EACH Aid Year )

6. Are you enrolled in a Distance Learning Program?

Yes**

(**if Yes and using CH 33 you are only entitled to ½ the national average BAH rate)

7. If using VA CH 33, are you

the Veteran

a Dependent

Spouse

8. If using VA CH 35 Education Benefits for the first time please list the following: Veterans File #:________________

Payee #____________ (this # can be obtained from the VA 1-888-442-4551)

9. Provide updated address, if it has recently changed:

________________________________________________________________________________________________________

I hereby authorize the Office of Veteran Services and Financial Aid to submit the VA enrollment certification for the term(s) listed above.

**You must agree to the statements below by checking the boxes**



I understand that completion of this form assures me of enrollment certification with the Department of Veterans Affairs, but does not guarantee

payment from the VA. Payment depends on my enrollment in an approved program, not owing money to the VA for overpayment, and

compliance with all other VA regulations.



I agree to immediately notify the Office of Veteran Services and Financial Aid if I drop, add, or withdraw classes.



I understand that only courses listed in my program plan can be certified and that if my program plan changes, I must submit an

updated copy to the Office of Veteran Services and Financial Aid.



I understand that if I continue to receive benefits based on an incorrect enrollment certification, because I dropped a class and failed to notify

the Office of Veteran Services and Financial Aid, that I will owe the excess amount of benefits received back to the Department of Veterans

Affairs.



I understand that if my VA benefits exhaust and the University does not receive payment on my behalf, I will owe the unpaid balance to the

University.



I understand that notifications and requests for additional information to process this request will be sent to my UTHSCSA LiveMail Account.

_____________________________________________

__________________________________

Signature

Date

The UTHSCSA is an Equal Opportunity/Affirmative Action Institution. Pursuant to the Americans with Disabilities Act, if you require

this information in an alternative format please contact the Office of Veteran Services and Financial Aid for assistance.

7703 Floyd Curl Drive MSC 7708 San Antonio, TX 78229-3900

210 567-2635

210 567-6643 fax

Renewal Va Item Checklist Page 2

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